State Complaint Number for MLTC Problems - 1-866-712-7197
Managed Long Term Care (MLTC) plans are insurance plans that are paid a monthly premium ("capitation") by the New York Medicaid program to approve and provide Medicaid home care and other long-term care services (listed below) to people who need long-term care because of a long-lasting health condition or disability. The MLTC plans take over the job the local CASA or Medicaid offices used to do – they decide whether you need Medicaid home care and how many hours you may receive, and arrange for the care by a network of providers that the plan contracts with.. They also approve, manage and pay for the other long-term care services listed below.
In addition to this article, for latest updates on MLTC --see this NEWS ARTICLE on MLTC Implementation.
- Free Webinar recorded April 24, 2014 on MLTC --available for online viewing explaining Managed Long Term Care and the upcoming expansion to require new nursing home residents to enroll in MLTC plans, or, for those without Medicare, into mainstream managed care plans. The webinar was conducted by Valerie Bogart and David Silva of the Evelyn Frank Legal Resources Program at NYLAG.
You can also view and listen to a recording of the entire webinar at this link:
https://attendee.gotowebinar.com/recording/1348252302283983105 (2.25 hours)
The PowerPoint and Appendix used in the webinar are available at the following links:
90-Day Transition Period - On May 8, 2013, the State extended the time that MLTC plans must continue providing the same amount and type of home care services that new members previously received from a CASA, DSS, or CHHA from 60 days to 90 days. Read more about the Transition Period.
In General -- NYS Shift from a Voluntary Option to Mandatory Enrollment in MLTC
New York has had managed long term care plans for many years. Before, however, enrollment was voluntary, and MLTC was just one option of several types of Medicaid home care one could choose. Other choices included personal care services, approved by the local CASA/DSS office, Lombardi program or other waiver services, or Certified Home Health Agency services. On Sept. 4, 2012, the federal government Medicaid agency "CMS" approved the state's request for an "1115 waiver" that will allow NYS to require that all dually eligible (those who have Medicare and Medicaid) adults age 21+ now receiving -- or who will apply for -- community-based long-term care services -- particularly personal care/home attendant services, long-term Certified Home Health Agency services, Consumer-Directed Personal Assistance program services (CDPAP), private duty nursing and medical adult day care -- to enroll in a Managed Long-Term Care (MLTC) plan. The MLTC plan will now control access to, approve, and pay for all Medicaid home care services and other long-term care services in the MLTC service package. This is the only way to obtain these services for adults who are dually eligible, unless they are exempt or excluded from MLTC.
If they do not choose a MLTC plan then they will be auto-assigned to a plan.
NYS DIRECTIVES, CONTRACTS, POLICY GUIDANCE -- Medicaid Redesign Team page - scroll down to MRT 90 - Managed Long Term Care -- documents include the following but check as often updated: Click on
The monthly premium that the State pays to the plans "per member per month" is called a "capitation rate." The amount of this premium is the same for every enrollee, but it is not a cap on the cost of services that any individual enrollee may receive. Instead, the plan must pool all the capitation premiums it receives. The rate is supposed to be enough for the plan to save money on members who need few services, so that it can provide more services to those who need more care. To make it more confusing, there are two general types of plans, based on what services the capitation rate is intended to cover:
I. "Partial Capitation" -- Managed Long-Term Care Plans - "MLTC" - Cover certain Medicaid services only
"Managed long-term care" plans are the most familiar and have the most people enrolled. They provide Medicaid long-term care services (like home health, adult day care, and nursing home care) and ancillary and ambulatory services (including dentistry, optometry, audiology, podiatry, eyeglasses, and durable medical equipment and supplies), and receive Medicaid payment only, with NO Medicare coverage.
These plans DO NOT cover most primary and acute medical care. Members continue to use their original Medicare cards or Medicare Advantage plan, and regular Medicaid card for primary care, inpatient hospital care, and other services. The MLTC plan does not control or provide any Medicare services, and does not control or provide most primary MEDICAID care. Managed long-term care plan enrollees must be at least age 18, but some require a minimum age of 21. See state's chart with age limits.
It is this partially capitated MLTC plan that is becoming mandatory for adults age 21+ who need Medicaid home care and other community-based long-term care services. But consumersl have the option of enrolling in "fully capitated" plans as well -- so it's important to know the differences. A summary chart is posted here.
II. "Full Capitation" - Plans cover all Medicare & Medicaid services -- PACE & Medicaid Advantage Plus
PACE and Medicaid Advantage Plus plans provide ALL Medicare and Medicaid services in one plan, including primary, acute and long-term care. All care must be in plan's network (hospitals, doctors, nursing homes, labs, clinics, home care agencies, dentists, etc.). For these plans, your need for daily care must be such that you would be eligible for admission to a nursing home. When you join one of these plans, you give up your original Medicare card or Medicare Advantage card. Instead, you use your new plan card for ALL of your Medicare and Medicaid services. There are 2 types of FULL CAPITATION plans that cover Medcaid long-term care:
(1) PACE "Programs of All-Inclusive Care for the Elderly" plans - must be age 55+ See CMS PACE Manual. Link to federal PACE regs - 42 CFR Part 460. and other guidance on PACE :
(2) MEDICAID ADVANTAGE PLUS [MAP] - age requirements vary among plans from 18+ to 65+
NOTE: MEDICAID ADVANTAGE PLANS are a slight variation on the MEDICAID ADVANTAGE PLUS plans. They provide and control access to all primary medical care paid for by MEDICARE and MEDICAID, EXCEPT that they do not cover most long-term care services by either Medicaid or Medicare. Anyone who needs Medicaid home care should NOT join this 3rd type of plan!
See this chart summarizing the differences between the four types of managed care plans described above. The chart also includes a 5th type of managed care plan - Medicaid Managed Care - these plans are mandatory for most Medicaid recipients who do NOT have Medicare. The capitated payment they receive covers almost all Medicaid services, including personal care and CHHA home health aide services, with some exceptions of services that are not in the benefit package.
See this chart of plans in NYC organized by insurance company, showing which of the different types of plans are offered by each company as of Feb. 2013
Statewide County by County Chart created by NYLAG (NYC on PAGE 4) showing the number enrolled in each of the various plans as of april 2015 2014
Chart organized by insurance company, which sponsors the plan, showing which different MLTC/MAP/PACE plans are offered by the company as of March 2014. Shows which companies are launching FIDA plans in 2014.
http://www.nymedicaidchoice.com/program-materials - NY Medicaid Choice lists - same lists are sent to clients with 60-day Choice letters. CAUTION -- Look only at the Long Term Care plans - ("Health Plans" are Mainstream managed care plans, which are NOT for Dual Eligibles)
- See more enrollment numbers - for various NYS plans that provide Medicare and Medicaid services for dual eligibles, including Medicare Advantage plans - here.
Month to Month enrollment growth in MLTC and PACE from 2013 to July 2013 is at Page 5 at this link.
WHO MUST ENROLL -- Medicaid recipients who:
See links to press coverage in this article under APRIL 2013 News.
Phase -In of mandatory MLTC -
MLTC was phased in beginning in Sept. 2012 in New York City through July 2015 gradually rolling out to all counties in NYS, and including all of the services listed above. See details of the phase in schedule here.
WHO MAY NOT ENROLL IN A MLTC? (Who is EXCLUDED from MLTC?)
Individuals in Certain Waiver Programs. These include: Nursing Home Transition & Diversion (NHTD) waiver, Traumatic Brain Injury (TBI) waiver, Office for People with Developmental Disabilities waiver, and individuals with complex mental health needs receiving services through ICF and HCBS waiver. (Note NHTW and TBI waivers will be merged into MLTC in January 1, 2022, just extended from 2019 per NYS Budget enacted 4/1/2018).
Nursing Home residents WERE excluded from enrolling in MLTC plans or mainstream Medicaid managed care plans but MAY enroll as of Oct. 1, 2015. New permanent residents MUST enroll. SEE this article.
Medicaid Assisted Living Program residents - still excluded, but will be carved into MLTC;
Persons receiving hospice services (they may not enroll in an MLTC plan, but someone already in an MLTC plan who comes to need hospice services may enroll in hospice without having to disenroll from the MLTC plan. See NYS DOH MLTC Policy 13.18: MLTC Guidance on Hospice Coverage (June 25, 2013) Those who are in hospice and need supplemental home care may still apply to CASA/DSS for personal care services to supplement hospice;
Residents of Intermediate Care Facilities for the Developmentally Disabled (ICF/DD), Alcohol & Substance Abuse Long Term Care Residential Program, adult Foster Care Home, or psychiatric facilities.
People who receive or need ONLY "Housekeeping" services ("Personal Care Level I" services under 18 NYCRR 505.14). Under state law, these services are limited to 8 hours per week. If someone does not need assistance with Activities of Daily Living - personal care such as bathing, grooming, walking but only with household chores, they access these services through their Local Medicaid Program (in NYC apply to the Home Care Service Program with an M11q. See --
Children under age 18
NOTE - the recently obtained (2/2013) New York Medicaid Choice MLTC Exclusion Form excludes an individual certified by physician to have a developmental disability.
SOURCE: CMS Special Terms & Conditions, Amended Sept. 2012), at p. 14 -15
Download New York Medicaid Choice MLTC Exclusion Form - must be signed by physician
WHO MAY ENROLL IN MLTC BUT IS NOT REQUIRED TO? (WHO is EXEMPT FROM MLTC?)
Dual eligible individuals age 18- 21 who require home care or other long-term care services, and require a “nursing home level of care,” meaning they could be admitted to a nursing home based on their medical and functional condition;
Adults over age 21 who have Medicaid but not Medicare (If they require a “nursing home level of care”) -- If they are not yet enrolled in a a mainstream Medicaid managed care plan they may opt to enroll in an MLTC plan if they would be functionally eligible for nursing home care. If they enroll in an MLTC, they would receive other Medicaid services that are not covered by the MLTC plan on a fee-for-service basis, not through managed care (such as hospital care, primary medical care, prescriptions, etc.). However, if they are already enrolled in a mainstream Medicaid managed care plan, they must access personal care, consumer-directed personal assistance, or private duty nursing from the plan. They may only switch to MLTC if they need adult day care, social environmental supports, or home delivered meals - services not covered by Medicaid managed care plans. See MLTC Policy 14.01: Transfers from Medicaid Managed Care to Managed Long Term Care
Working Medicaid recipients under age 65 in the Medicaid Buy-In for Working People with Disabilities (MBI-WPD) program (If they require a “nursing home level of care”).
SOURCE: CMS Special Terms & Conditions, Amended Jan. 2014, at p. 14
Under MLTC Policy 14.06: Implementation of the Conflict-Free Evaluation and Enrollment Center (CFEEC) anyone approved for Medicaid who is seeking Managed Long Term Care will need to first contact NEW YORK MEDICAID CHOICE and request a CFEEC assessment. If that assessment finds the person eligible for MLTC, then the person can enroll in an MLTC plan. To schedule an evaluation, call 855-222-8350.
SEE NEW YORK MEDICAID CHOICE WEBSITE ON CFEEC - http://nymedicaidchoice.com/ask/conflict-free-evaluation-and-enrollment-center
NYLAG's Guide and Explanation on the CFEEC and MLTC Evaluation Process
This is being implemented pursuant to #28 of the Special Terms and Conditions, which is CMS's approval of the State's 1115 waiver to implement mandatory MLTC, DOH has established a conflict-free assessment system for all voluntary enrollments into MLTC, MAP and PACE effective October 1, 2014.
Before, private MLTC plans were responsible for determining eligibility for Medicaid-covered long-term services and supports (LTSS). This creates an intrinsic conflict of interest, because plans have a financial stake in avoiding high-cost members and attracting low-cost members. The CFEEC reduces this conflict by having New York Medicaid Choice (aka Maximus), rather than the MLTC plans, determine eligibility for MLTC.
The Conflict-Free Evaluation and Enrollment Center (CFEEC)s schedule and conduct initial assessment visits in the home or facility by a nurse (employed by or under contract with the CFEEC). Using the Uniform Assessment Tool, the CFEEC makes the determination of eligibility for Medicaid LTSS. If the CFEEC determines that the applicant is ineligible for Medicaid LTSS, it will send a written notice with appeal rights. If the CFEEC approves the applicant, then any MLTC, MAP, PACE or FIDA plan must accept the applicant's enrollment. If the plan disagrees with the CFEEC's determination of eligibility, it may pursue a dispute adjudication procedure via Maximus and DOH.
The CFEEC was rolled out in phases beginning in NYC in October 2014, and became statewide by May 2015.
MLTC plans may not accept an enrollment without confirmation from CFEEC that you are MLTC-eligible.
Does CFEEC expire? Yes, you must enroll in a plan and the plan must submit your enrollment form to DSS and Maximus within 75 days of the date of the CFEEC. (This was extended from 60 days in lDecember 2016 - see MLTC Policy 16.08: Conflict Free Evaluation and Enrollment Center (CFEEC) Update to Expiration of Evaluations. Please note that the clarification that the signed enrollment form must be submitted by the plan by the 75th day was made in response to a query submitted by NYLAG. If you have signed the enrollment form by the 75th day, but plan has not submitted it by the 75th day, you may still be able to enroll without needing a new CFEEC. Call DOH MLTC line at 1-866-712-7197 if there is a problem.
- The State FAQ (Q13) says the CFEEC assessment can be done while Medicaid application is pending, but since a Medicaid application can take more than 75 days - it can be risky.
See policies available from NYS DOH on the Conflict-Free Evaluation and Enrollment Center (CFEEC) at https://www.health.ny.gov/health_care/medicaid/redesign/mrt90/index.htm:
WHICH SERVICES ARE PROVIDED BY THE MLTC PLANS - Benefit Package of "Partially Capitated" Plans
MLTC plans must provide the services in the MLTC Benefit Package listed below. Once you are enrolled in a MLTC plan, you may no longer use your Medicaid card for any of these services, and you must use providers in the MLTC plan’s network for all of these services, including your dentist. The providers will be paid by the MLTC plan, rather than billing Medicaid directly.
MLTC Benefit Package (Partial Capitation) (Plan must cover these services, if deemed medically necessary. Member must use providers within the plan's provider network for these services).
- Home Care, including:
- Adult Day Health Care (medical model and social adult day care)
- Personal Emergency Response System (PERS),
- Nutrition -- Home-delivered meals or congregate meals
- Home modifications
- Medical equipment such as wheelchairs, medical supplies such as incontinent pads, prostheses, orthotics, respiratory therapy
- Physical, speech, and occupational therapy outside the home
- Hearing Aids and Eyeglasses
- Four Medical Specialties:
- Audiology + hearing aides and batteries
- Optometry + eyeglasses
- Non-emergency medical transportation to doctor offices, clinics (ambulette)
- Nursing home care
SOURCE: NYS DOH Model Contract for MLTC Plans (See Appendix G), CMS Special Terms & Conditions, Amended Sept. 2012), at p. 57, Attachment B
NOTE WHICH SERVICES ARE NOT COVERED BY MLTC PARTIALLY CAPITATED PLANS -- but are covered by "fully capitated" Medicaid Advantage Plus or PACE plans
- Primary and acute medical care, including all doctors other than the Four Medical Specialties listed above, all hospital inpatient and outpatient care, outpatient clinics, emergency room care, mental health care
- Lab and radiology tests
- Prescription drugs
- Assisted living program
- Hospice services - MLTC plans do not provide hospice services but as of June 24, 2013, an MLTC member may enroll in a hospice and continue to receive MLTC services separately. Before s/he had to disenroll from the MLTC plan. PACE plans may not give hospice services. See NYS DOH MLTC Policy 13.18: MLTC Guidance on Hospice Coverage (June 25, 2013)
HOW DO PEOPLE IN MLTC Partial Capitation Plans Receive services not covered by the plans? These use -
- Original Medicare OR Medicare Advantage plan AND
- Regular Medicaid
WHAT SERVICES ARE "MEDICALLY NECESSARY?" The Federal Medicaid statute requires that all managed care plans make services available to the same extent they are available to recipients of fee-for- service Medicaid. 42 U.S.C. § 1396b(m)(1)(A)(i); 42 C.F.R. §§ 438.210(a)(2) and (a) (4)(i). The NYS DOH Model Contract for MLTC Plans also includes this clause: “Managed care organizations may not define covered services more restrictively than the Medicaid Program"
You will receive a series of letters from New York Medicaid Choice (www.nymedicaidchoice.com), also known as MAXIMUS, the company hired by New York State to handle MLTC enrollment. See PowerPoint explaining Maximus/NY Medicaid Choice's role in MLTC enrollment (this is written by by Maximus)
"ANNOUNCEMENT " LETTER - Important Medicaid Notice-- This "announcement letter" is sent to people with 120 days left on their authorization period for Medicaid personal care, certified home health agency, private duty nursing, CDPAP, and medical model adult day care, or LOmbardi services, telling them "MLTC" is coming letter sent in English and Spanish. It does not state that they have to enroll yet.. just says that it is coming and to expect a letter.
MANDATORY ENROLLMENT PACKET - Sent by NY Medicaid Choice 30 days after the 1st "announcement" letter - stating recipient has 60 days to select a plan OR will be assigned to an MLTC plan. The first packets were sent in Manhattan in July 2012, telling them to select a plan by September 2012, later extended to October 2012. The Packet includes:
Form Letter to Personal Care/Home Attendant recipients (at this link with sample envelope) -- It also includes the toll-free number of the enrollment broker, NY Medicaid Choice, for consumers to call with questions about MLTC and help picking a plan..: 888-401-6582.
Official Guide to Managed Long Term Care, written and published by NY Medicaid Choice (Maximus)
List of Long Term Care Plans in New York City - 3 lists mailed in packet, available online - http://nymedicaidchoice.com/program-materials - NOTE: At this link, do NOT click on the plans listed as "Health Plans" - those are mainstream Medicaid managed care plans that are NOT for people with Medicare. Look for the "Long Term Care" plans for your area - NYC, Long Island, or Hudson Valley.
NYC lists -
MLTC Medicaid Plans - New York City
Medicaid Advantage Plus - New York City
Program of All-Inclusive Care for the Elderly (PACE)
CONTINUITY OF CARE -- One important factor in choosing a plan is whether you can keep your aide that worked with you when CASA/DSS, a CHHA, or a Lombardi program authorized your care before you enrolled in the MLTC plan. When MLTC began, the plans were required to contract with all of the home care agencies and Lombardi programs that had contracts with the local DSS for personal care/ home attendant services, and pay them the same rates paid by the local DSS in July 2012. That requirement ended March 1, 2014.
If you don't select and enroll in a plan, midway through the 60-day period to select a plan, you will receive a letter with the name of the MLTC plan to which you will be randomly assigned if you do not select a plan. You will still have til the third Friday of that month to select his/her own plan. For example, the first assignment letters to lower Manhattan residents were sent Oct. 2, 2012. If those individuals enrolled in a different plan by Oct. 19, 2012, their own selection would trump the auto-assignment, and they would be enrolled in their selected plan as of Nov. 1, 2012.
HOW DO I ENROLL IN A PLAN --
ONCE you select a plan, you can enroll either directly with the Plan, by signing their enrollment form, OR if you are selecting an MLTC Partially Capitated plan, you can enroll with NY Medicaid Choice. If you are selecting a Medicaid Advantage Plus (MAP) or PACE plan, you must enroll directly with the plan.
WHEN IS MY ENROLLMENT IN AN MLTC PLAN EFFECTIVE?
Enrollment in MLTC, MAP and PACE plans is always effective on the 1st of the month. The plan is paid its "capitation" rate or premium on a monthly basis, so enrollment is effective on the 1st of the month.
If you enrolled late in the month (after the third Friday of the month), the enrollment will not be effective -- and the new plan will not take charge of your care -- until the first of the second month after you enroll.
NEW APPLICANTS -- If you were not previously receiving Medicaid personal care, CDPAP, CHHA Lombardi, private duty nursing or adult day care program services --
Must request a Conflict-Free Eligibility assessment. Click here for more information.
If were already receiving Medicaid home care, adult day care, home health aide, private duty nursing, or Immediate Need personal care or CDPAP services, before you were required to enroll in the MLTC plan, the MLTC plan must provide the same services and the same number of hours as CASA/DSS/CHHA had authorized for 90 days.
The CMS Special Terms & Conditions states:
"Initial transition into MLTC from fee-for-service. Each enrollee who is receiving community-based long-term services and supports that qualifies for MLTC must continue to receive services under the enrollee's pre-existing service plan for at least 60 days after enrollment, or until a care assessment has been completed by the [MLTC], whichever is later."
During this 90-day Period (directive of the State on May 8, 2013, the plan must assess the new members needs in her home. SOURCE: CMS Special Terms & Conditions 9/2012 sec.17(d)(ii)(1)(c)(p. 19). The plan’s nurse will decide how much care the plan will approve for after the 60-day transition period.
90-day transition policy applies if your MLTC plan closed altogether or in your county, so you were required to join a new plan. See this article on your rights when plans close.
Plan must give written notice with appeal rights and a justification before reducing services after the TRANSITION PERIOD If the plan wants to reduce or end the services after the Transition Period. the plan must give you a WRITTEN NOTICE of the reduction that can be effective no earlier than the 90th day after your enrollment. The notice must comply with MLTC Policy 16.06: Guidance on Notices Proposing to Reduce or Discontinue Personal Care Services or Consumer Directed Personal Assistance Services, which applies longstanding due process principles that prohibit reductions in services without a justification. Grounds for a reduction may include that the medical condition improved or social circumstances changed. The notice must explain your right to appeal. See this article re Appeals and Grievances in Managed Long Term Care for more information on your right to appeal. Note that since May 1, 2018, you must first request an Internal Appeal within the plan, and then, if you lose, you will receive a notice from the plan explaining you have the right to request a Fair Hearing. You are entitled to continue receiving the old services, without any reduction until the internal appeal and then the hearing is decided (Aid Continuing).
The Plan's nurse conducts an assessment using a standardized assessment tool, which was changed to the Uniform Assessment System Tool (UAS) --
MRT 69: Uniform Assessment System for Long Term Care in NYS -- Uniform Assessment System – New York Overview and Status
UAS-NY Project Update Webinar December 14, 2012 1 Hour Recorded Session, PowerPoint Presentation
Before, assessment was by the SAAM -- MLTC Semi-Annual Assessment of Members (SAAM) Tool - version 2.5 -- Both tools collect demographic information, diagnosis, living arrangements, and functional abilities. This tool does not determine the number of hours. Most plans use their own proprietary "task" form to arrive at a number of articles. Consumer advocates are concerned that the State has not clearly required plans to provide personal care, CHHA and other services in the same amount, duration, and scope as is provided in the state-plan outside of MLTC. See standards and regulations that apply under NYS Medicaid for personal care, CHHA, consumer-directed personal assistance (CDPAP) and other home care services.
MLTC Policy 16.07: Guidance on Task–based Assessment Tools for Personal Care Services and Consumer Directed Personal Assistance Services - clarifies standards such as:
Task-based assessment tools cannot be used to establish inflexible or “one size fits all” limits on the amount of time that may be authorized ... or the frequency at which such tasks can be performed. Plans must conduct individualized assessments of each enrollee’s need for assistance with IADLs and ADLs. This means that plans must permit the assessments of time, as well as frequency, for completion of a task to deviate from the time, frequency, or other guidelines set forth in the tool whenever necessary to accommodate the enrollee’s individualized need for assistance.
When an enrollee requires safety monitoring, supervision or cognitive prompting to assure the safe completion of one or more IADLs or ADLs, the task-based assessment tool must reflect sufficient time for such safety monitoring, supervision or cognitive prompting for the performance of those particular IADLs or ADLs....
...Example of supervision and cognitive pairing A cognitively impaired enrollee may no longer be able to dress without someone to cue him or her on how to do so. In such cases, and others, assistance should include cognitive prompting along with supervision to ensure that the enrollee performs the task properly."
See more helpful guidance in the directive.
The State Dept. of Health notified MLTC plans that they must comply with revised regulations that are used in assessing the need for Personal Care Services and CDPAP. In particular, these changes modify who is eligible for 24-hour care, specify requirements for the content of notices when plans deny or reduce services, and make other changes. For a full description of the changes for personal care, see this article. The changes governing CDPAP are similar, and the article on CDPAP will be updated soon.
In 2015, the State amended the regulations that define who is eligible for 24-hour continuous care (also known a s "split shift") and for the first time defined eligibility for 24-hour live in care. See MLTC Policy 15.09: Changes to the Regulations for Personal Care Services (PCS) and Consumer Directed Personal Assistance (CDPA) Notice of Adoption
The State issued guidelines for "mainstream" Medicaid managed care plans, for people who have Medicaid but not Medicare, which began covering personal care services in August 2011 -- Guidelines for the Provision of Personal Care Services in Medicaid Managed Care.
The Federal Medicaid statute requires that all managed care plans make services available to the same extent they are available to recipients of fee-for- service Medicaid. 42 U.S.C. § 1396b(m)(1)(A)(i); 42 C.F.R. §§ 438.210(a)(2) and (a) (5)(i). The NYS DOH Model Contract for MLTC Plans also includes this clause: “Managed care organizations may not define covered services more restrictively than the Medicaid Program." This is language is required by 42 C.F.R. §§ 438.210 (a) (5)(i).
All decisions by the plan as to which services to authorize and how much can be appealed. See Appeals & Greivances in Managed Long Term Care.
Both federal regulations at 42 CFR 438.210 (amended in 2016 effective in NYS May 1, 2018) and the NYS DOH Model Contract for MLTC Plans (Appendix K - section 3. "Service Authorizations) dictate the deadlines for the plan to give you a decision when you request new services or an increase in existing services, such as home care.
The contract uses these terms to explain these requests. Note that the contract has not been updated to include the changes in the federal regulation effective in NYS May 1, 2018, but the changes are nevertheless binding on plans since they must comply with federal law and regs).
A Prior Authorization is a request by the Enrollee or provider on Enrollee’s behalf for a new service (whether for a new authorization period or within an existing authorization period) or a request to change a service as determined in the plan of care for a new authorization period.
A Concurrent Review is a request by an Enrollee or provider on Enrollee’s behalf for additional services (i.e., more of the same) that are currently authorized in the plan of care or for Medicaid covered home health care services following an inpatient admission.
EXPEDITED REQUEST -- In either of the above two types of requests, the member or provider may request that it be expedited - if the plan determines or the provider indicates that a delay "would seriously jeopardize the enrollee’s life or health or ability to attain, maintain, or regain maximum function". If the plan denied the Enrollee’s request for an expedited review, the plan will handle as standard review.
DEADLINES FOR PLAN TO PROCESS -- Contract and 42 CFR 438.210 provide that Plan must decide and notify Enrollee of decision by phone and in writing as fast as the Enrollee’s condition requires but no more than:
a. Prior authorization
- Expedited - 72 hours from request for service, subject to extension described below, if criteria are met.
- Standard – within 3 business days of receipt of necessary information, but no more than 14 calendar days of receipt of request for services, subject to extension described below.
b. Concurrent review
- Expedited – within 72 hours of receipt of request, on, subject to up to 14-day extension described below.
- Standard – within 14 calendar days of receipt of request, subject to up to 14-day extension described below.
- In a request for Medicaid covered home health care services following an inpatient admission, one (1) business day after receipt of necessary information; except when the day subsequent to the request for services falls on a weekend or holiday, seventy-two (72) hours after receipt of necessary information; but in any event, no more than three (3) business days after receipt of the request for services.
14-DAY EXTENSION OF ABOVE DEADLINES including Expedited Requests -- Up to 14 calendar day extension may be requested by Enrollee or provider on Enrollee’s behalf (written or verbal). The plan also may initiate an extension if it can justify need for additional information and if the extension is in the Enrollee’s interest. In all cases, the extension reason must be well documented.
- The plan must give the enrollee written notice of the reason for the decision to extend the timeframe and inform the enrollee of the right to file a grievance if he or she disagrees with that decision; and Issue and carry out its determination as expeditiously as the enrollee's health condition requires and no later than the date the extension expires. 42 CFR 438.404(c).
If the plan does not issue a decision on a request for services within the timeframes specified in § 438.210(d) described above, this constitutes a denial and is thus an adverse action, which can be appealed just as a written decision can be appealed. 42 CF.R. 438.404(c)(5). See article on Appeal & Grievances in MLTC.
Lock-In - For the first time since MLTC became mandatory 5 years ago, members who enroll in a new plan after an implementation date will be barred from changing plans for 9 months, after the first 90 days. (The effective date was scheduled for Dec. 1, 2018 - but is not yet scheduled as of Jan. 11,2019 pending CMS approval.) The JUNE 2018 Medicaid Update (PDF), a State DOH publication for Medicaid health care providers, gives further detail about this change. See 2018-2019 Enacted Budget Initiative: MLTC Partial Capitation Plans Enrollment Lock-In This change was enacted in the NYS Budget April 2018. NY Public Health Law § 4403-f, subd. 7(b)(vii).
Beginning on a date in 2019 to be announced, if approved by CMS (postponed from December 1, 2018), MLTC Partial Capitation plans will have enrollment lock-in periods. People who enroll either by new enrollment or plan-to-plan transfer after the to-be-announced effective date in 2019 will have a 90-day grace period to elect a plan transfer after enrollment. They then will be locked in to that plan for nine months after the end of their grace period (for a total period of one year from the date of enrollment). People who were enrolled in an MLTC partial capitation plan prior to the to-be-announced effective date in 2019 may still change plans after that date when they choose, but then will be locked in to the new plan after the 90th day after enrollment.
- GOOD CAUSE - EXCEPTION TO LOCK-IN --After the initial 90-day grace period, enrollees will have the ability to disenroll or transfer if they can present evidence of good cause. While not an exhaustive list, the following circumstances are examples of good cause:
- the enrollee is moving from the plan's service area,
- the plan fails to furnish services, or
- it is determined the enrollment was non-consensual.
Plans will retain the ability to involuntarily disenroll for the reasons specified in their contract, which includes:
- failure to pay spend-down,
- hospitalization for greater than 45 days, or
- the enrollee was absent from the service area for more than 30 consecutive days.
After the completion of the lock-in period, an enrollee may transfer without cause, but is subject to a grace period and subsequent lock-in as of the first day of enrollment with the new MLTC partial capitation plan.
This change does not impact the integrated (fully capitated) plans: Fully Integrated Duals Advantage (FIDA), Medicaid Advantage Plus (MAP), and the Program of All-Inclusive Care for the Elderly (PACE). Enrollees will have the ability to enroll into an integrated plan at any time, and the integrated plans do not have a lock-in period.
WARNING ABOUT CHANGING PLANS during "grace period" or for good cause:
Don’t sign up for a new plan unless the new plan confirms that it will approve the services you want and the hours you need. You may call any plan and request that they send a nurse to assess you and tell you what services they would provide. You have the right to receive the result of the assessment in writing.
- IF A PLAN CAN ONLY BEGIN SERVICES ON THE 1ST OF ANY MONTH, WHAT DO I DO IF I NEED SERVICES RIGHT AWAY, or WHEN I GET OUT OF THE HOSPITAL OR A REHAB CENTER?
Use the Immediate Need procedure to request personal care or CDPAP services from the local DSS/HRA, which can be approved within 1-2 weeks. After 120 days of receiving these services, the individual will be required to enroll in an MLTC plan. She will have "transition rights," explained here.
- I HAVE A SPEND-DOWN (SURPLUS INCOME). WHAT HAPPENS IF I DON’T PAY IT? The MLTC plan will bill you for the spend-down. If you don’t pay it, the MLTC plan may disenroll you. If you live in NYC or another mandatory county, you will not be able to get Medicaid home care or other long-term care services.
MLTC's may Disenroll Member for Non-payment of Spend-down - The HRA home attendant vendors were prohibited by their contracts from stopping home care services for someone who did not pay their spend-down. Similarly, CHHA's are prohibited by state regulation from stopping services based on non-payment. FN 4. MLTC programs, however, are allowed to disenroll a member for non-payment of a spend-down. See model contract p. 15 Article V, Section D. 5(b). While the State's policy of permitting such disenrollment is questionable given that federal law requires only that medical expenses be incurred, and not paid, to meet the spend-down (42 CFR 435.831(d)), the State's policy and contracts now allow this disenrollment.
SPEND-DOWN TIP 1 --For this reason, enrollment in pooled or individual supplemental needs trusts is more important than ever to eliminate the spend-down and enable the enrollee to pay their living expenses with income deposited into the trust. For more information about pooled trusts see http://wnylc.com/health/entry/6/.
SPEND-DOWN TIP 2 - for new applicants who will have a Spend-Down - Request Provisional Medicaid Coverage -- When someone applies for Medicaid and is determined to have a spend-down or "excess income," Medicaid coverage does not become effective until they submit medical bills that meet the spend-down, according to complicated rules explained here and on the State's website. Many people applying for Medicaid to pay for long-term care services can't activate their Medicaid coverage until they actually begin receiving the services, because they don't have enough other medical bills that meet their spend-down. This creates a catch-22, because they cannot start receiving MLTC services until Medicaid is activated. If they apply and are determined eligible for Medicaid with a spend-down, but do not submit bills that meet their spend-down, the Medicaid computer is coded to show they are not eligible. As a result, an MLTC plan could refuse to enroll them -- because they do not have active Medicaid. To address this problem, HRA recently created a new eligibility code for "provisional" Medicaid coverage for people in this situation. This is explained in this Medicaid Alert dated July 12, 2012. Applicants who expect to have a spend-down should attach a copy of this Alert to their application and advocate to make sure that their case is properly coded.
See this article
For the latest on implementation of MLTC in 2013 see these news articles:
PHASE 1 - Sept. 2012 in New York City adult dual eligibles receiving Medicaid personal care (home attendant and housekeeping) were "passively enrolled" into MLTC plans, if they did not select one on their own after receiving "60-day letters" from New York Medicaid Choice, giving them 60 days to select a plan. See enrollment information below. Over the end of 2012 and through mid-2013, NYC recipients of CDPAP, CHHA, adult day care, Lombardi, and private duty nursing services begin receiving 60-day enrollment letters to select an MLTC plan in 60 days. See enrollment information below.
See HRA Alert. and DOH Directive Approved Long Term Home Health Care Program (LTHHCP) 1915 (c) Medicaid Waiver Amendment
August 2013 - THose individuals needing solely housekeeping services (Personal Care Level I), who were initially required to join MLTC plans, are no longer eligible for MLTC. New applicants may again apply at the local DSS and those already receiving MLTC are transitioned back to DSS. See MLTC Poliucy 13.21
Phase II WHERE: Nassau, Suffolk, and Westchester counties
WHO: Dual eligibles age 21+ who need certain community-based long-term care services > 120 days newly applying for certain community-based Medicaid long-term care services.
WHICH SERVICES: Medicaid personal care, CDPAP, Medicaid adult day care, long-term certified home health agency (CHHA), or private duty nursing services, and starting in May 2013, Long Term Home Health Care Waiver Program (LTHHCP) or (“Lombardi”) participants, must enroll in these plans. Those already receiving these services begin receiving "Announcement" and then "60-day letters" from New York Medicaid Choice, giving them 60 days to select a plan. See enrollment information below.
See Approved Long Term Home Health Care Program (LTHHCP) 1915 (c) Medicaid Waiver Amendment
Also in Jan. 2013, for New York City -- mandatory enrollment expands beyond personal care to adult dual eligibles receiving medical model adult day care, private duty nursing, or certified home health agency (CHHA) services for more than 120 days, and in May 2013, to Lombardi program.. These individuals begin receiving "announcement" and then 60-day enrollment notices.. described below.
Phase III (September 2013) (Postponed from June 2013): Rockland and Orange counties - "front door" closed at local DSS offices Sept. 23, 2013 - after that Medicaid recipients must enroll directly with MLTC plan to obtain home care.
Phase IV (December 2013): Albany, Erie, Onondaga and Monroe counties - See below explaining timeline for receiving letters and getting 60-days to enroll.
Phase V (2014) Roll-out schedule for mandatory MLTC enrollment in upstate counties during 2014, subject to approval by CMS. , Source: NYS DOH Updated 2014-2015 MLTC Transition Timeline (PDF, 88KB) (MRT e-mails) NYS DOH Policy & PLanning Updates January 2015 and February 2015
||"MLTC Announcement" letter sent
||60-day "Choice" letters sent
||"Front door" closed - no new Personal Care applications at local Medicaid office
|9/2012 - 12/2013
NYC, Albany, Erie, Monroe, Nassau, Onondaga, Orange, Rockland, Suffolk, Westchester
||Columbia, Putnam, Sullivan, Ulster
||early May 2014
||May __ 2014
||Cayuga, Herkimer, Oneida, and Rensselaer
||Week of May 23, 2014
||week of June 2, 2014
||Greene, Saratoga, Schenectady, and Washington
||Week of June 30th
||Week of July 14
||July 7, 2014
||Dutchess, Montgomery, Broome, Fulton, Schoharie
||Week of Aug. 29th
||Week of Sept. 22nd
||September 8, 2014
||Niagara, Madison, Oswego
||Week of Oct. 27, 2014
||Chenango, Cortland, Livingston, Ontario, Steuben, Tioga, Tompkins, Wayne
||Genesee, Orleans, Otsego, Wyoming
||Week of December 29, 2014
||Jan. 5, 2015
||Chautauqua, Chemung, Seneca, Schuyler, Yates, Allegany, Cattaraugus
||Clinton, Essex, Franklin, Hamilton, Jefferson, Lewis, St. Lawrence
||Allegany, Clinton, Franklin, Jefferson, Lewis, and St. Lawrence.
||July 3, 2015
For more information please see:
Consumer Concerns on Mandatory Enrollment in Managed Long Term Care
In August 2012, a letter was sent from The Legal Aid Society, Empire Justice Center, NYLAG, CIDNY, and other consumer, disability rights and community-based organizations asking for further protections in rolling out MLTC. Consumers ask that MLTC be rolled out more gradually, so that it starts with new applicants seeking home care only, rather the tens of thousands of people already receiving personal care/home attendant services. Consumers also express concerns about appeal rights being limited if and when MLTC plans reduce services compared to what the individual previously received from the Medicaid program. See the letter for other issues.
In March 2012, consumer advocacy organizations proposed Incentives for Community-Based Services and Supports in Medicaid Managed Long TermCare: Consumer Advocate Recommendations for New York State.
On December 27, 2011, Legal Aid Society, New York Lawyers for the Public Interest, and many other organizations expressed concerns to CMS in this letter. These concerns include violations of due process in fair hearing appeals.
On May 2, 2011, Selfhelp Community Services led numerous organizations in submitting these comments, explaining numerous concerns about the expansion of MLTC
The Long Term Care Community Coalition published Transition To Mandatory Managed Long Term Care: The Need for Increased State Oversight - Brief for Policy Makers. and other information on its MLTC website.